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Asked by sfatimata1987

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Chief
Complaint:
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Social
History:
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Inpatient
Medications:
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Neuro:
A&0x3.
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Cultures:
Blood-
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Blood-
Peripheral
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Prioritized Problem List

 

Problem list:

Medical Problem

Drug Therapy Problem

Supporting Evidence

Status

Intervention

1)

 

 

 

 

2) 

 

 

 

 

3)

 

 

 

 

4) 

 

 

 

 

5) 

 

 

 

 

6) 

 

 

 

 

7) 

 

 

 

 

8) 

 

 

 

 

9) 

 

 

 

 

10) 

 

 

 

 

*You may subtract or add more boxes if needed

            

 

Calculated objective data (must include units and show calculations to receive credit) 

 

 

IBW: ______

 

 

CrCl: ______

 

 

BMI: ______  

 

 

BMI classification (circle one of the following): underweight    normal     overweight     obesity class ____

 

 

Other: 

Any other calculation that may be pertinent to the specific case (Example: LDL-C, corrected calcium, anion gap, etc.)

 

 

                                                                        

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S:   

(All pertinent subjective findings for all problems)

 

 

O:    

(All pertinent objective findings for all problems)

 

 

A:

(Assessment statements for each problem)

1)

 

2)

 

3)

 

4)

 

P: 

(Complete plan for each assessment statement)

Recommendation(s): 
Efficacy Monitoring:
Safety Monitoring:
Patient Education/Counseling:
Follow-up:
 Recommendation(s):  
Efficacy Monitoring:
Safety Monitoring:
Patient Education/Counseling:
Follow-up:
Recommendation(s): 
Efficacy Monitoring:
Safety Monitoring:
Patient Education/Counseling:
Follow-up:
Recommendation(s): 
Efficacy Monitoring:
Safety Monitoring:
Patient Education/Counseling:
Follow-up:

 

SCIENCE
HEALTH SCIENCE
NURSING
NURS 6560N

 

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